Acupractitioner21 is the sequel to the underground hit Acustudent21, from one of the periods when I was training in Chinese medicine. This blog will focus on Classical Chinese Medicine, CCM, the old system, and on what it´s like to practice acupuncture in the West in the 21st century. The name might have changed, but like everybody in old Chinese medicine, I am still a student.

måndag 13 augusti 2012

Some thoughts on the differences between Classical Chinese Medicine and TCM

I thought I´d spend a blogpost to think about Classical Chinese Medicine and how it is defined.
Classical Chinese Medicine is the oldest version of Chinese medicine that we know of. There are of course different schools within CCM too, but there are some main tenets and views that form the core of it. In the 1950´s and onwards, the creation of what today is called Traditional Chinese Medicine, TCM, began in Chinese universities and hospitals. TCM has a stronger influence from Western medicine. Even later, in the 1980´s and onwards, fragments of the original system was used to create what is now called Western Acupuncture, WA.

I simply thought to write down some definitions, some ideas, and some views on the practices that are part of Classical Chinese Medicine.

Classical Chinese Medicine is close to the roots that Chinese medicine has in Daoism. Daoism is an ancient Chinese spiritual tradition that is still alive and practiced today. But there is still a difference between CCM and Daoyi, pure Daoist medicine. A minority of practitioners are trained in both (see Jeffrey Yuen, quoted later in the text).

I think that one of the first, simplest (and yet most complex) things that shapes Classical Chinese Medicine is that everything is one. This is pure Daoism and shows the Daoist roots of Chinese medicine very clearly. In Daoism, one name for Dao, the Way, is Yiqi – One Energy. That everything is the same energy. When Daoists started to treat people this view followed. The patient´s system is one, and that wholeness should ideally move in a fairly balanced way with its surroundings. One could indeed see Classical Chinese Medicine as a way of first helping the patients system to weave together to be one again, and then how to help that oneness weave into more balance with its surroundings: its place in time and space – a Daoist view applied through the use of intent through needles.

As we learn to practice, there is of course a separation. We have to understand pieces to see how they become a whole. But that sense of oneness should always be in the background, like being aware not just of the actor saying lines but of all the other ones on stage too, and the backdrop they are moving through, all at the same time. One whole: not a coir of individual voices.

This first and basic tenet is probably the one that is most difficult for Westerners to truly understand and manifest. To genuinely see a patient as one, and how to treat that weave to be more balanced and even more healthy and whole, takes a lot of time and often a lot of practical work involving meditation and/or qigong to be able to do. The deeper a person thinks in Western medical terms, for example, the more difficult it will be for them to shift to TCM, and even more difficult to access CCM. To me, anything else in Classical Chinese Medicine grows from this seed of seeing the patient as one.
The next question becomes how to diagnose this, and how we can let treatments slowly move deeper in the patient´s system to help them balance it to whatever level they are looking for.

There are of course some pure technical differences between what is called CCM and TCM too – some follow traditions from the Neijing or Nanjing, Shan Hanlun, family lineages, various schools of Daoism etc. – but for me, the next point would be a precise focus on the whole including a deep understanding of shen. Shen is our conscious awareness, and the manifestion of this through our health and through our life. Jeffrey Yuen, a well-known practitioner of both CCM and Daoist medicine, says ”Jing is shen manifested.”Jing is the innate strength of our physical body. It is also the blueprint for how our physical body and physicality will evolve over our lifetime. It will become the physical manifestation of our shen.
(For an interview with Jeffrey Yuan on how shen is the root of all diseases, see http://www.accm.ie/all-diseases-are-rooted-in-the-spirit/)

Paying attention to shen is mentioned in TCM, but the actual understanding and genuine interest in it seems to get less and less as time goes on. Classical Chinese Medicine has a deep interest in the patient´s shen and how it weaves into their physical existence. As CCM researches this, it gives us as individuals a very deep understanding of how shen works. First we learn about our own shen, then more and more how it works in everybody else. From that point, it grows even bigger and becomes a compassionate understanding of how all shen sees life and is affected by it.
This work in CCM gives a fundamental understanding of how shen weaves into the imbalances we have. But through it, we also learn how treatment can be tailored not only to help patients to become healthier, but more free.

A third thing that I have noticed is the difference in diagnosis. The bagang – the eight – are used in CCM, but the bianzheng – the patterns – are more commonly the staple of TCM. Over the last few decades, this has increased to become more influenced by Western medicine and its interest in looking for one thing that is wrong and then treating only that. CCM and its practitioners are more interested in understanding the underlying functions instead, and, again, how they weave together with the patient´s shen. Sometimes, the pure TCM version can seem like someone who is fascinated with maps instead of walking through the landscape.

A tangent off this is palpation of the body and the jingluo, the meridians. Palpation has been a part of CCM since at least the Neijing, though different dynasties has seen the emphasis on it vary. The latest one during the 20th century in China has been one of the downturns: palpation became rare in Chinese medicine in general in the 20th century. Sometimes this has been because of what social class was being treated, sometimes simply how the entire society thought. (You can read more about palpation in the post about Dr Wang Juyi and his system for channel diagnosis here: http://www.acupractitioner21.blogspot.se/2012/07/channel-palpation-and-channel-theory.html).
In his book The Long Road, Edward Obaidey comments about the difference between practitioners of TCM (rarely palpation based) and Meridian Style Acupuncture in Japan (very palpation oriented). The TCM practitioners he met seemed open about their work, proud of it and very rapid and clear in diagnosis. Initially, he stayed away from the Meridian Style practitioners since they seemed more uncertain, doubtful about what they did, and reticient to talk about it. Maybe one reason for this was the work with palpation: once practitioners start using it as a regular tool in clinic, the certainty of memorized bianzheng patterns soon vanish out the window. The mental constructs of diagnosis that were so clear, suddenly vanish when faced with the living complexity of the patient´s body, energy-system, and mind.

In the book Applied Channel Theory in Chinese Medicine, Dr Wang Juyi is asked by his co-author Jason Robertson if he ever saw some plan to kill or dilute CCM be implemented in the universities and hospitals were Dr Wang worked. Since he graduated with the first ever university class as an acupuncture doctor, Dr Wang trained and worked all through the entire time of the birth of TCM. Dr Wang simply said ”No.” He never saw any conscious plans to water down the old knowledge. What seemed to be the main factors were simply that it was planned into university exams and modules instead of the traditional (and still living) apprentice system of CCM, and then also the influence of xiyi, Western medicine, with, finally, how the communists demanded an integration of it into hospitals.
This view is echoed by Elisabeth Hsu in her book The Transmission of Chinese Medicine. ”TCM, in spite of being called ”traditional” (chuantong), is generally referred to as the ”modernised” (xiandaihuade), ”scientific” (kexuehuade), ”systematic” (xitonghuade), and ”standardized,” (guifanhuade) Chinese medicine. In awareness of how ideology-laden these attributes were, one doctor called TCM the ”School of the colleges” (xueyuanpai), which implied that it was just one of many ”schools” of Chinese medicine. However, government offficials, if not aiming at its monopoly, advocated its predominance.”
– The Transmission of Chinese Medicine, Elisabeth Hsu, Cambridge University Press, 1999

Calling TCM Xueyuanpai instead, the School of Colleges, would explain a lot more about it´s views and rationale, and be a clearer definition of it as just one of the schools in Chinese Medicine. The way TCM has been made more theoretical – for good and for bad put into a modern university format – has also unfortunately made it easier to create theoreticians rather than practical clinicians.

Xu continues with a comment that parallells that of Dr Wang: ”TCM is distinct also in respect of its institutional setting: the colleges, hospitals, and cliincs are all institutions of the Chinese socialist state; so called work units (gongzuo danwei). It is within such socialist institutions that Chinese medicine has been modernised, Westernised, standardized, and made scientific. However, the modernisation of every day life has affected all medical practices within and outside government institutions. Often closely interrelated with a certain westernisation, ”science” or ”scientific” is a ubiquitously found attribute for any therapy. It is only in government institutions that the aim of standardizing chinese medical learning has been formulated and pursued. Comparisons of this government-promoted medicine with other chinese therapeutics will allow us to identify both strengths and limitations of the standardisation of medicine.” – ibid

(For those interested in the differences between CCM and TCM, and how it came about, Xu´s book can really be recommended. In it, she follows the evolution of university courses in the 1980´s in China, comparing it with CCM practitioners and with laoyisheng, old doctors, who still at that time were trained, like Dr Wang, by doctors trained pre-Revolution in China.)

”You can´t use all of the indications for a point unless you do cultivation practices.”
- Jeffrey Yuen in lecture, 2011

This writer sees qigong and meditation-work as crucial to Classical Chinese Medicine. It is important to remember that a majority of the early practitioners were often Daoists, who have in-depth qigong- and meditation practice as a standard thing in their tradition. Daoism is based on practical training-techniques, and it is quite possible that the writers of the Neijing and Nanjing thought it a given that anybody reading the texts would have a stable practice as part of their life too.

A stable qigong- and/or meditation-practice will completely change what the practitioner can do and treat in clinic. The qigong stabilizes our own system, builds up energy in it, relaxes it, heals it at ever deeper levels over decades of practice, and gives the practitioner the skill to clean out the effect patients have on their system after long hours in clinic. The relaxation we have, the energy we have, will also act as catalysts for the same in our patients. Good quality qigong gives us the ability to feel our bodies and energy-systems with a very high level of precision – something that completely changes the ability to understand how the needles affect both us and our patients.
Same with meditation. In a sense, this is even more important, as it gives us the ability to create a mind more free from pre-conceived notions of diagnosis, and helps clean up our heart to become more free and compassionate. This becomes more important the longer we work. Daoism has specific practices concerning this used in the setting of health-workers.

(Note: this is for a longer and different post, but remember to only train qigong and meditation from a skilled practitioner. Never practice from DVD´s, video or audio tape.You want to rather spend a long time looking for a good teacher; it will repay itself enormously in the long run. Find someone you can have at least semi-regular contact with, as this kind of stabilizing effect is very important in both qigong and meditation training. It becomes even more important over the long run when the training and evolution of each student needs to be regularly tailored and stabilized. For a medical anthropology overview of zouhuo rumo, energy injuries due to incorrectly practiced or badly supervised training, see Breathing Spaces – qigong, psychiatry, and healing in China, by Nancy Chen, Columbia University Press 2003)

There are practitioners of CCM who don´t have a stable practice going and who still seem to be very skilled in it, but in my experience, those with long-time and stable practice can reach even deeper levels of skill and treatment ability, as well as simply in the completeness of their own life.

There is of course also technical knowledge that still exists in CCM and often has been lost in TCM. This includes both physical, energetic and mind-based diagnostic techniques as well as treatments that seem to have been lost in TCM. The fairly basic thing of palpation of the body and its meridians, for example, is rare to find in TCM, yet has survived in Japanese acupuncture, and is seen as a foundation diagnostic technique there.

”Everything in the Classics is there for a reason, but sometimes we don´t know how to interpret it.” – Dr Wang Juyi in lecture, 2012

So, is it either TCM or CCM? I don´t know. I don´t think so. I think it is, like everything else in life, a scale. There are of course certain technical skills that makes practitioners´ treatments more TCM or more CCM (say, Neijing views of not using more than three channels in a treatment, and not putting double needles on one channel to avoid over-treatment etc., echoed by Dr Wang Juyi in his lecture in Dublin this year, ”Don´t make the mistake that the more points is better,” he emphasized. ”It is quite harmful to the body.”), but in the long run, I think the difference between TCM and CCM is all down to the intent manifested by the practitioner in the meeting with the patient. There are specific qigong- and meditation-techniques taught for this, but the general intent of Classical Chinese Medicine goes back to that the patient is a whole, and that it is this whole that is helped to go back to being more whole again – helping this weave to heal, helping it weave back smoother with the surroundings that is the big weave of our life and society.
TCM still usually says it sees the patient as a whole, but diagnosis and treatment often shows a marked influence from Western medicine. Sadly, this seems to increase every decade so far.

Seeing the patient´s system as a living environment goes back to Daoism, and is echoed very strongly in the Nanjing, the Classic of Difficulties. Here we see the views that even xue, acupuncture points, have their own life that weaves together with the body and helps it heal. We will look at this Nanjing-view and its roots in Daoism and in the Shanhaijing, The Classic of Mountains and Seas, in a coming post.

”Zhenshi Dao – The Way of Needles.”
– Elisabeth Rochat de la Vallée on Classical Chinese Medicine, healing, and transformation, in lecture 2010

The view of Classical Chinese Medicine in the meeting of practitioner and patient, and the catalyst of healing that we should be, is seen quite clearly in its Daoist version in the Neiye, the Classic of Internal Training, from 350 BC.

IX.

Those who can transform even a single thing, call them ”numinous”;those who can alter even a single situation, call them ”wise”.But to transform without expending vital energy; to alter without expending wisdom:only exemplary persons who hold fast to the One are able to do this.Hold fast to the One; do not lose it,and you will be able to master the myriad things.Exemplary persons act upon things,and are not acted upon by them,because they grasp the guiding principal of the One.
– Neiye, Original Tao, Inward Training and the Foundations of Taoist Mysticism, Harold Roth, Princeton University Press, 1995

(Translation note: there are some things worth adding here. Most Daoists texts are instruction manuals in code. What is translated here as ”numinous” is the character shen. Shen is the same shen discussed earlier in this blogpost about the focus in Classical Chinese Medicine. In Daoism, shen also has the connotation of an enlightened individual or someone who has trained in the practices of Daoism for a very long time. This text discusses the practices for being able to move with change yet effect change without letting it cost the practitioner too much – like a catalyst that creates a catalyzing process without itself changing. Daoism studies change, and the tradition is entirely built up around practices of qigong and meditation with huge amounts of information to slowly work through over a lifetime. The original practices of baoyi, of embracing the one, mentioned in the text, can be seen echoed in the comments in the Neijing of, ”When needling, feel like you are standing at the edge of an abyss”, ”When holding a needle, feel like you are holding a tiger” and ”When needling, concentrate your mind without paying attention to things outside.” Actually, it has links to the following advice too, of ”When needling, set right the spirit (shen) of the patient”, as someone with the practices can do this quite easily before and during needling. All these have links to both the training and to the practices of being able to have a relaxed but very clear focus - and being able to have this over and over again in clinic, over decades of patients. This should first be trained in depth for the practitioner her- or himself, then it is transferred into treating patients. The list of advice is from Neijing chapter 54, Zhen Jie, Explanation on Needles.)

Today, Classical Chinese Medicine is a slowly growing movement in the West. TCM is still the most common version to be found, of course, but a steadily growing interest in the old versions of Chinese medicine is spreading. A few teachers actually have both old knowledge and sometimes the training-techniques that goes into using it, and are willing to share it here. Even apprenticeship-schools are starting in the West. We will keep discussing Classical Chinese Medicine here on Acupractitioner21 in the future, and wish you luck in your own journey – both in your own health, your own heart, and in that of your patients´.